Andersen et al.

BMC Family Practice (2019) 20:89

https://doi.org/10.1186/s12875-019-0984-x

RESEARCH ARTICLE Open Access

Danish general practitioners have found

their own way of using point-of-care
ultrasonography in primary care: a
qualitative study
Camilla Aakjær Andersen1* , Annette Sofie Davidsen2, John Brodersen3, Ole Graumann4 and Martin Bach Jensen1

Abstract
Background: General practitioners increasingly use point-of-care ultrasonography despite a lack of evidence-based
guidelines for their appropriate use in primary care. Little is known about the integration of ultrasonography in
general practice consultations and the impact of its use on patient care. The purpose of this study was to explore
general practitioners’ experiences of using ultrasonography in the primary care setting.
Methods: Adopting an explorative phenomenological approach, we performed semi-structured interviews with
general practitioners who used ultrasonography in their daily work. Thirteen general practitioners were recruited
stepwise, aiming for maximum variation in background characteristics. Interviews were conducted at the general
practitioner’s own clinic. Transcription and systematic text condensation analysis began immediately after
conducting each interview.
Results: The general practitioners described using ultrasonography for both selected focused examinations and for
explorative examinations. The two types of examinations were described differently for each of the following
emerging themes: motivation for using ultrasonography, ultrasonography as part of the consultation, selection of an
ultrasound catalogue, and consequences of the general practitioner’s ultrasound examination.
The general practitioners had chosen and integrated their own individual ultrasound catalogue of focused
examinations as a natural part of their consultations. The focused examinations were used to answer simple clinical
questions and they had a significant impact on the patients’ diagnoses, clinical pathways and treatments. The
general practitioners considered their own catalogue of focused examinations as their comfort zone. However, they
also performed explorative ultrasound examinations outside their catalogue. These scans were performed to train,
gain or maintain ultrasound competences or as explorative examinations driven by curiosity. The explorative
ultrasound examinations rarely had an impact on patient care.
Conclusions: This study describes how general practitioners found their own way of using ultrasonography in
general practice and selected a personal catalogue of ultrasound examinations that was applicable, relevant and
meaningful for their daily clinical routines. This study may serve to inform implementation strategies in general
practice by offering insights into central aspects that drive general practitioners’ behaviours.
Keywords: General practice, Family medicine, Primary care, Point-of-care ultrasound, Ultrasonography,
Implementation, Qualitative methods, Interviews

* Correspondence: caakjaer@dcm.aau.dk
1
Center for General Practice at Aalborg University, Fyrkildevej 7, 1,13, 9220
Aalborg Øst, Denmark
Full list of author information is available at the end of the article

© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Andersen et al. BMC Family Practice (2019) 20:89
Background
The application of ultrasonography as an integrated
part of clinical examinations has disseminated into
many clinical specialities [1]. Today, ultrasound
equipment is the size of a laptop, is affordable and
improved resolution facilitates image interpretation.
Moreover, the concept of point-of-care ultrasonog-
raphy allows clinicians to focus on answering simple
clinical questions e.g. ruling-in or out an abdominal
aortic aneurism rather than providing a full descrip-
tion of an anatomical region [2].
Evidence from hospital settings supports clinicians’ use
of ultrasonography as a bedside test providing earlier
and more correct diagnosis and better subsequent treat-
ment of patients [3, 4]. Some have argued that general
practitioners (GPs) should also use frontline ultrasonog-
raphy in their daily work [5–7]. However, there is very
limited research informing GPs about which examina-
tions to perform, how to integrate ultrasonography in
general practice consultations and the overall advantages
and disadvantages of using ultrasonography in general
practice [8]. Evidence from the hospital setting is not ne-
cessarily transferable, as working conditions, patient
populations and especially the epidemiology of symp-
toms of pathology is very different between the primary
and the secondary sector. This challenges the opportun-
ities for continuous supervision and the overall amount
of ultrasound examinations, which is essential to gain or
maintain competence. Moreover, GP workload is already
high [9, 10] and adding ultrasonography may reduce GP
accessibility for patients. Nevertheless, ultrasonography
use has already spread; it is now used by GPs in several
countries [8, 11], and the practice may disseminate fur-
ther as GPs desire more point-of-care tests in general
practice [12].
Attempts to guide the implementation of ultrasonog-
raphy in general practice have been made [13]. In
Denmark, a special interest group under the Danish
College of General Practitioners (DSAM) developed a
non-evidence-based consensus list of recommended
ultrasound scans suited for GPs [14] (Additional file 1).
However, knowledge dissemination regarding this list
has been limited to a Facebook group [15], short
reports on the DSAM homepage [16] and regional
meetings for GPs with a special interest in ultrasonog-
raphy. There are no official evidence-based guidelines
on how to use ultrasonography in general practice, no
educational programme for GPs or GPs in training, no
description of what training is needed, and no registra-
tion of GPs using ultrasonography.
Previous implementation research in general practice
has focused on exploring GP behaviours in relation to
an externally imposed guideline or intervention [17]. By
exploring the implementation of ultrasonography in
Page 2 of 11
general practice as an intervention introduced by GPs
themselves, we may gain new insights into what moti-
vates GPs towards changing their behaviours.
The use of ultrasonography among GPs in Denmark is
limited to a minority of enthusiastic GPs [11] who navi-
gate through uncharted waters. These GPs may possess
valuable knowledge about how ultrasonography can be
integrated and used in general practice consultations.
Hence, the purpose of this study was to explore these
GPs’ experiences in using ultrasonography in the pri-
mary care setting.
Method
We used an explorative phenomenological approach
[18] with individual semi-structured interviews to gain
in-depth knowledge about the GPs’ experiences with
ultrasonography.
All interviews were conducted, audio-recorded, tran-
scribed verbatim and analysed by CAA, who is a medical
doctor with clinical experience in general practice and of
using ultrasonography in this setting. As CAA was very
close to the field of interest, CAA’s assumptions and pre-
suppositions were declared in a written document prior
to commencing the study. Awareness about her pre-
sumptions made CAA more prepared to bracket these
during the interviews.
Setting
Denmark has a public healthcare system where almost
all patients are listed with a GP for primary healthcare.
The GP acts as a gatekeeper to secondary care.
Treatment is financed by taxes and is free of charge for
patients. GPs are paid by a mixture of capitation and
fee-for-service reimbursement. GPs are free to select
suitable services, but presently they receive no extra pay-
ment for performing ultrasound examinations, and ex-
penses for ultrasound training and equipment must be
covered by the GPs themselves.
Participant selection
We recruited GPs (medical doctors with a full post-
graduate specialization in family medicine) working in
general practice from all over Denmark. Information
about the study was distributed through ultrasonog-
raphy teaching sessions, regional small-group learning
meetings and the Danish GPs’ ultrasonography
Facebook group [15]. Interested GPs were invited to
provide their contact information and background
characteristics through a small information form de-
signed for this purpose (Additional file 2). Thirty-four
GPs signed up to participate. From these 34 GPs, we
purposely selected participants aiming for maximum
variation in the following background characteristics:
age, gender, experience as a GP, experience with
Andersen et al. BMC Family Practice (2019) 20:89
ultrasonography, extent of chosen ultrasonography
range, location in Denmark and organisational aspects
of the practice. Recruitment was stepwise, aiming for
10–15 participants based on the concept of information
power [19]. Recruitment stopped when no new know-
ledge emerged during the interviews.
Interviews
The interviews were conducted at the GPs’ clinics to sup-
port and maintain their role as healthcare professionals in
their everyday working environment. An interview guide
(Additional file 3) was developed based on knowledge
gained from a systematic literature review [8] and infor-
mal focus group discussions with GPs. The interview
guide provided domains and suggested questions. How-
ever, the semi-structured nature of the interview meant
that CAA could deviate from the structure and follow the
interviewees’ narratives and any possibilities that arose.
All participants provided their informed consent to
Fig. 1 Systematic text condensation in this study. This figure illustrates and elaborates the analytic process in this study
Page 3 of 11
participate. Transcriptions and audio recordings were
anonymised according to the regulations of the Danish
data protection agency.
Data analysis
We used systematic text condensation [20]. This is an
inductive cross-case analysis consisting of four steps:
total impression, identifying an sorting meaning units,
condensation, and synthesizing (Fig. 1). Interviews
and analysis were conducted in Danish. The analytical
results and quotes were later translated to English in
collaboration with a professional translator.
Results
Thirteen GPs were included in the study between
August 2016 and March 2017. Their characteristics are
shown in Table 1. The GPs reflected a large variation in
the use of ultrasonography regarding organs scanned,
clinical conditions examined for and decisions made
Andersen et al. BMC Family Practice (2019) 20:89 Page 4 of 11

Table 1 Characteristics of participants (N = 13) varied from supervised training during residency to ex-
Characteristic No tensive formalised education in line with specialists’
Age training.
40–50 years 6
Regardless of level of experience, all GPs described
two ways of using ultrasonography in their daily prac-
51–60 years 4
tice: selected focused ultrasound examinations and ex-
61–70 years 3 plorative ultrasound examinations. The distinction
Gender between the two types was very clear among the novice
Male 11 GPs and was less pronounced among the most experi-
Female 2 enced GPs. Moreover, four themes were revealed: motiv-
Experience as a general practitioner
ation for using ultrasonography, ultrasonography as part
of the consultation, selection of an ultrasound catalogue,
> 20 years 3
and consequences of the GP ultrasound examination.
10–20 years 6 The characteristics of each type of examination and the
< 10 years 4 four themes are elaborated in detail below and the inter-
Experience using ultrasonography in general practice action between themes is presented in Fig. 2.
< 2 years 7
2–5 years 4 Two ways of using ultrasonography in general practice
Selected focused ultrasound examinations
> 5 years 2
All GPs described primarily using ultrasonography for
Extent of ultrasonography use
selected point-of-care examinations to answer a clinical
Restricted to a few anatomical areas 5 question raised by a patient’s history and/or by a phys-
According to the DSAM “common trunk” 5 ical examination of the patient. These selected examina-
Broad use 3 tions were limited to the description of specific organs
Frequency of ultrasonography use and conditions within these organs. Hence, the examina-
tions were performed only on symptomatic patients
Several times a day (1–8) 4
where the GPs aimed to confirm or disconfirm their
Once a day 3
clinical suspicions.
Several times a week 5
Several times a month 1 “I ask myself: Is this kidney big and has it distended
Practice location due to hydronephrosis? If it turns out that there is a
Urban 8
single bubble in the kidney’s parenchyma – well that’s
not what I asked myself, so I don’t consider it”
Mixed 5
(GP15).
North Denmark Region 2
Central Denmark Region 4 The GPs explained that these limited ultrasound ex-
Region of Southern Denmark 2 aminations were different from traditional ultrasound
Region Zealand 0 examinations performed by radiologists.
Capital Region of Denmark 5
“It is a clinical and not a diagnostic scan. To us, the
Practice size
ultrasound scan is just a tool. So I am not afraid to
< 2000 patients 4
make – My scan isn’t a final document, unlike if I
2000–5000 patients 4 made something called a diagnostic scan.” (GP13).
> 5000 patients 5
Type of practice Focused GP ultrasound examinations were restricted
Partnership practice 9 to rule-in pathology and not rule-out. However, some
GPs said that they could rule out certain clinical condi-
Solo-practice 2
tions, e.g. spontaneous abortion, if they detected foetal
Cooperation practice 2
heart movements in an intrauterine foetus.
When GPs performed focused ultrasound examina-
based on the ultrasound examination. The GPs had be- tions, they worked within their comfort zone – their se-
tween a few months and more than 10 years of experi- lected usual catalogue and they talked about the
ence with ultrasonography, and all had participated in examinations with pride, providing several examples that
some ultrasound training. The extent of the training underlined the importance of these examinations. They
Andersen et al. BMC Family Practice (2019) 20:89 Page 5 of 11

Fig. 2 Two ways of using ultrasonography. This figure illustrates the interaction between themes in the analysis and the distinction between
selected focused ultrasound examinations and explorative ultrasound examinations within each theme
Andersen et al. BMC Family Practice (2019) 20:89
had experience in doing these examinations, felt suffi-
ciently trained within this field and performed the exam-
inations on a regular basis. They felt sure that they
could perform the examinations and interpret the ultra-
sound images. Hence, they said that performing their fo-
cused ultrasound examinations provided them with a
sense of reassurance.
Explorative ultrasound examinations
Although the GPs talked about the importance of know-
ing the extent and limits of their abilities and staying
within their comfort zone, they all recounted that they
sometimes deviated from their usual catalogue and per-
formed more explorative ultrasound examinations.
These extended examinations were performed either to
train ultrasound competences or simply explore possible
explanations for a patient’s symptoms without having a
clear clinical suspicion of a specific disease.
Ultrasonography performed to train ultrasound com-
petences was described by both novice and experienced
GPs. The goal was to try new types of ultrasound exami-
nations, to practice difficult ultrasound competences or
simply train or maintain skills. These training examina-
tions were often an extension of a focused examination
of organs without clinical indication:
“If I scan for – let’s say gall stones – then I also locate
the spleen and I check the kidneys and include the
aorta, include the bladder…” (GP8).
Other ultrasound examinations were explorative by
nature and mainly performed by GPs with more ultra-
sound experience. In these examinations, the GPs said
that they did not have a clear focus, but they hoped they
might find something that explained the patient’s symp-
toms. These examinations were clearly outside the GPs’
comfort zone and often not part of their previous ultra-
sound training.
“I sometimes extend my usual catalogue (.) when I
think something is potentially interesting, but
always with reservations uhm (…) I am (.)
somewhat on shaky ground and I am prepared to
say -if there is anything I am unsure about, then I
refer it” (GP3).
The GPs talked about these examinations with some
hesitation, underlining their explorative nature and in-
security. The GPs stated that they often aborted these
examinations without reaching a conclusion.
Motivation for using ultrasonography
The GPs described that they used ultrasonography for
the sake of patients and society, but also out of self-
Page 6 of 11
interest. They felt that they improved patient care by in-
creasing patients’ access to ultrasonography and by being
able to complete patient treatment in general practice
without referral. The GPs believed that they reduced the
number of patients referred for further examination in
the secondary healthcare sector, thereby reducing overall
healthcare costs and at the same time providing better
service for their patients. They also said that they could
provide diagnostic certainty for patients and reduce their
health concerns.
Most GPs claimed that their primary motivation for
using ultrasonography was increased job enthusiasm
and professional contentment. Ultrasonography gave
them more satisfaction in their everyday work. They
said that working as a GP had become more fun, ex-
citing and varied after they had begun using ultrason-
ography. When they performed focused examinations,
they felt that ultrasonography enabled them to per-
form better as a GP.
“Really, we are using it for our own satisfaction and to
get better at diagnosing things. Being more certain
about, for example, being able to guide an injection
somewhere or things like that. It is a tool that helps
us on a daily basis.” (GP4).
Explorative examinations gave the GPs’ professional-
ism a boost.
“I could just have done a normal exam - maybe there
is a filling to the left, maybe not - and then send a
referral – but now [after the ultrasound] I was able to
send a referral where it is noted that I have found
something measuring such and such and having more
than one chamber, you know? That is – I think –
really great.” (GP5).
The GPs said that they were fascinated by the technol-
ogy and the possibility of seeing and diagnosing path-
ology that was previously out of reach. Some described
feeling motivated by being first-movers, as they firmly
believed that ultrasonography was part of the future in
general practice.
Ultrasonography as part of the consultation
The GPs described using ultrasonography as a natural
continuum in consultations after hearing the patient’s
history and conducting physical examinations. Focused
ultrasound examinations were not seen as an outstand-
ing examination, but rather as an integrated part of the
diagnostic process – a supplement interpreted together
with the patient’s history and the physical findings. Fo-
cused examinations were compared to other diagnostic
tests in general practice, e.g. ECG, CRP or stethoscopy,
Andersen et al. BMC Family Practice (2019) 20:89
and the GPs described how they integrated ultrasound
in the same way:
“I see the scanner as an extension of my fingers; of
course, I also examine people’s abdomen with my
hands. In situations where I feel the edge of a liver
below the curvature, I could use the scanner to
explore if the liver extends [.] below the curvature. It
[ultrasound] confirms what I am already doing”
(GP15).
Explorative ultrasound scans were described as an
additional examination that was performed after the ini-
tial diagnostic process and a conclusion had been
reached. Indeed, some GPs described occasionally book-
ing patients for a new consultation to have enough time
to perform the ultrasound examination. Some GPs de-
scribed how the focused examinations were conducted
within the timeframe of the consultation, while others
described that the duration of the consultation was ex-
tended with 5–10 min, which sometimes made them fall
behind schedule.
Selection of an individual ultrasound catalogue
Individual selection
All the GPs said that they had selected an individual
ultrasound catalogue of focused examinations based on
their patient population, professional interests and ultra-
sound training. The individual catalogue included ultra-
sound examinations that were meaningful for the GP.
Most of the GPs had limited their catalogue to simple
clinical conditions within a few anatomical areas, while
more experienced GPs had a larger catalogue.
“We have also limited ourselves to some selected
musculoskeletal joints. Clearly, we can’t scan all
joints, so we have limited ourselves to specific joints –
partly to diagnose and also for giving ultrasound-
guided injections” (GP13).
None of the GPs expressed full commitment to the
DSAM list of recommended ultrasound scans for GPs.
Many were not aware of this list and the remaining GPs
said that they had either chosen some of the examina-
tions from the list or developed a personal catalogue that
exceeded the list.
Most of the GPs had an ultrasound training that was
more extensive than was reflected in their individual cata-
logue, and all described having excluded some ultrasound
examinations because they were considered “out of reach”
or without any impact for patients. Out of reach examina-
tions were described as being too difficult to perform, too
time-consuming, too rare in general practice or examina-
tions that the GP felt insufficiently trained to conduct.
Page 7 of 11
Ultrasound examinations without impact for patient care
were described as examinations where the diagnosis was
primarily clinical, e.g. a tennis elbow, or examinations
where a GP ultrasound examination could not replace
examination by an ultrasound specialist, e.g. a radiologist.
Generally, GPs were reluctant to scan children, and to
scan on patients’ requests. Some ultrasound scans, e.g.
screening of the abdominal aorta, life-threatening condi-
tions, and cancer-related scans, were excluded because the
GPs felt that they were ill-suited for general practice.
General practitioners are not radiologists
GPs described that using ultrasonography required educa-
tion, practice, dedication and technical and anatomical un-
derstanding, but most importantly humility and respect.
Ultrasonography was described as a user-dependent tech-
nology, and GPs emphasized that they were generalists and
not radiologists. They were not trying to do a radiologist’s
job. Indeed, they described their use of ultrasonography as
being limited to examinations on a different level.
“After all, there is a limit as to how skilled we can
become as we need to do other things, too; so of
course, you can’t reach the same level as the others
(radiologists), you can’t, and I don’t think that’s the
point, so I – it’s more to get by.” (GP14).
The GPs described how they – as generalists – were
used to performing at a certain level before referring pa-
tients to specialists and that knowing one’s limitations
was of paramount importance.
“In principle, you can scan everything, but you can’t
be good at everything.” (GP3).
Some of the GPs stated that radiologists could rule out
pathology using ultrasound examinations, while that
would never be the case with the limited examinations
in general practice. It was considered important and ne-
cessary to communicate about the differences between
ultrasonography performed by a radiologist and a GP
both to patients and specialists in the secondary health-
care sector to avoid false expectations.
Consequences of the GP ultrasound examination
The GPs described ultrasonography as having a big im-
pact on their diagnostic processes. They felt more
confident in their diagnosis after using ultrasound com-
pared to the traditional examination of patients, which
they felt entailed considerable uncertainties.
“You’re a little more confident that (.) what you are
doing is correct in terms of not risking mistreating
patients” (GP14).
Andersen et al. BMC Family Practice (2019) 20:89
The GPs recounted that focused ultrasound examina-
tions led to faster and more precise diagnosis and treat-
ment either in general practice or through more
qualified referrals to the secondary sector.
“I make better and higher quality diagnoses or
referrals” (GP5).
Two of the GPs argued that ultrasonography use in
general practice was merely a service improvement ra-
ther than an actual improvement in patient care. Overall,
patients were treated in the same way as before, but
diagnoses were reached faster, and more treatments were
finalised in primary care.
When the GPs carried out ultrasonography outside
their usual individual catalogue, they were aware that
they were doing this for their own benefit. Hence, they
were very cautious about drawing conclusions and tak-
ing consequences. Often, the plan for further action was
made beforehand, and ultrasonography only influenced
this in case of positive incidental findings. Several GPs
gave examples of cases with incidental findings. In all
these examples, the incidental findings were considered
to relate to a serious disease, e.g. cancer, and the pa-
tient’s clinical pathway was accelerated through fast-
track referrals. However, some incidental findings turned
out to be false alarms. Generally, more experienced GPs
felt more confident in their ultrasound findings than
novices did, and they described their ultrasound exami-
nations as having a greater impact on patient care.
Novice GPs were very careful about ruling out path-
ology. They still relied on their clinical examinations and
mostly used ultrasonography to confirm their clinical
findings.
All GPs described situations where they felt unable to
interpret ultrasound images and had to use their usual
treatments and pathways. This often entailed referring
patients for an ultrasound examination in the secondary
healthcare sector.
“Some patients are difficult to scan and some have
organs that are placed where you wouldn’t expect.
In those cases, you can’t answer clinical questions
with ultrasound, and so these patients receive the
treatment they would otherwise have received.”
(GP15).
The GPs expressed little concern about the risks of
their own use of ultrasonography. They said that mis-
diagnosis was only made by GPs with insufficient train-
ing, poor judgment of their own ultrasound skills or too
much use of ultrasonography for explorative purposes.
The GPs in this study were not concerned about over-
looking pathology in their limited scans as they were
Page 8 of 11
reluctant to rule out pathology based exclusively on the
scans. Overdiagnosis was described as a general concern
in the healthcare system and not specifically related to
their use of ultrasonography.
The GPs explained that they felt that ultrasonography
improved the doctor-patient relationship through better
dialogue and a more positive atmosphere in consulta-
tions. However, some GPs described that ultrasonog-
raphy gave them authority and increased the patient’s
confidence and respect for the doctor.
“The doctor becomes more appreciated because he is
more thorough, as he has this extra magical
examination, which is almost worse than the
stethoscope. You know, it’s crazy, now we can actually
see inside the body! That’s the kind of magic it has.”
(GP19).
The GPs experienced that the patients became reas-
sured by ultrasonography and generally, the GPs thought
that patients appreciated technology in GP consulta-
tions. However, some GPs expressed concern about pa-
tients’ reliance on the technology. Although the GPs
tried to explain these limitations, they felt unsure,
whether patients were able to understand these limita-
tions or differentiate between a specialist ultrasound
examination and a GP ultrasound examination.
Discussion
To our knowledge, this study is the first to provide an
in-depth understanding of GPs’ use of ultrasonography
in the primary healthcare setting. We found that GPs in
Denmark use ultrasonography in two different ways: se-
lected focused ultrasound examinations and explorative
ultrasound examinations. The former were selected
scans within each GP’s own individually chosen ultra-
sound catalogue. These examinations were believed to
have a high impact on patient care and provide reassur-
ance for both the GP and the patient. The GPs spoke
with pride about these examinations and gave several ex-
amples where their thought their use of these scans had
improved patients’ outcomes. However, the GPs did not
restrict themselves to performing only selected focused
examinations. They also described performing explora-
tive ultrasound scans that were beyond their individual
standard catalogue. These examinations were performed
to various degrees to either practise ultrasound skills or
find explanations for a patient’s symptoms. The GPs
talked about explorative ultrasound examinations with
some hesitation and underlined that they performed
these scans with caution. According to the GPs, explora-
tive scans rarely had an impact on patient care, but some
GPs described how incidental findings had resulted in
referral for further examination due to suspicion of a
Andersen et al. BMC Family Practice (2019) 20:89
serious disease. The GPs had few concerns about their
own use of ultrasonography. They believed they were
improving patient care and that they were first-movers
with this technology, which entailed learning by doing.
Strengths and limitations
We took several precautions to secure the confirm-
ability of this study: The coding and analytical process
was supervised by a senior qualitative researcher
(ASD) with no experience in ultrasonography and the
interview transcripts were re-read thoroughly, looking
for contradictory evidence of the distinction between
the two types of ultrasound examinations described in
Fig. 2. Furthermore, the results were compared to
CAA’s written assumptions and presuppositions to se-
cure the production of new knowledge.
We aimed for maximum variation in our sample.
However, the selection of GPs was limited to those
responding to our invitation. Only a few women and no
GPs from rural practices responded. This may have lim-
ited the credibility of our study.
The transferability of our results may be compromised
as our study only included GPs in general practice in
Denmark. The organisational aspects of the Danish
healthcare system such as workload in primary care, lack
of reimbursement for conducting ultrasonography and
availability of this technique for patients may influence
GPs’ ways of using ultrasonography. However, these or-
ganisational aspects have also been described in other
countries [21, 22]. Hence, our results are likely to extend
to GPs in other countries.
Findings in context
The GPs in this study described their use of ultrasonog-
raphy as something distinct from the traditional ultra-
sound examination performed by radiologists in the
secondary healthcare sector - not as an inferior examin-
ation, but as a separate examination. They described the
need for both types of examinations, that they were not
trying to be radiologists and that some ultrasound exam-
inations should still be undertaken by specialists. This
confirms a theory proposed by Weile et al. [2] that
point-of-care ultrasound performed by a clinician repre-
sents a case of disruptive innovation. They argue that
point-of-care ultrasound has a different trajectory than
the traditional full ultrasound examination with different
strengths, limitations, opportunities and patients. This
understanding may explain why the GPs in the present
study expressed little concern about their own use of the
technology.
The GPs were highly motivated and had implemented
ultrasonography in their daily clinical routines with no
organisational guidance or financial incentives. They had
found their own way and developed an individual
Page 9 of 11
catalogue of ultrasound examinations that were applic-
able, relevant and meaningful to them. This change in
practice – including a selection of ultrasound examina-
tions in daily routines – may be understood with respect
to the COM-B model introduced by Michie [23]. The
model describes Capability, Opportunity and Motivation
as central components that generate Behaviour and form
the Behaviour Change Wheel. When GPs performed
their selected ultrasound examinations, all three compo-
nents were met: the GPs felt that they possessed the ne-
cessary skills and knowledge (Capability); the ultrasound
examinations were integrated into the patient examin-
ation, conducted within the timeframe of the consult-
ation and the GPs had the equipment to perform the
examination (Opportunity). Finally, the GPs were highly
motivated to perform the examinations based on previ-
ous experiences. They believed that they performed bet-
ter as GPs, improved patient care and felt increased
professional satisfaction (Motivation). Moreover, some
ultrasound examinations were de-selected by the GPs
because they felt insufficiently trained or the examin-
ation was too difficult to perform (lack of Capability),
they did not have the necessary probes for the examin-
ation or time to perform the examination (lack of
Opportunity), or they felt that the examination did not
affect patient care (lack of Motivation).
Although the GPs’ educational levels differed consider-
ably, they all described occasionally performing ultra-
sound examinations to gain, train or maintain their
skills. Novice GPs primarily used ultrasonography for fo-
cused examinations, while more experienced GPs also
performed explorative scans without a specific clinical
question. This difference could be explained by the GPs’
different competence levels. Dreyfys and Dreyfys [24] de-
scribe professionals moving through five stages from
novice to expert. Rules and analytical reasoning domin-
ate the first steps of the learning process, while later
stages are dominated by intuitive use based on pattern
recognition. In our study, the more experienced GPs de-
scribed a more intuitive use of ultrasonography with a
less clear distinction between focused and explorative
use, while novice GPs predominantly stayed within their
comfort zone and described a more rigorous use.
Carraccio et al. [25] describe that learners require expos-
ure to environments and clinical scenarios outside their
normal comfort zone in order to stimulate their adaptive
higher-level clinical reasoning that is critical for trans-
forming proficient practitioners into expert practitioners.
Hence, the explorative examinations described by the
GPs in the present study may be seen as an inevitable
part of a learning process, although lack of opportunity
and capability also limit the extent of this process.
We found that GPs use ultrasonography for different
organs and with different indications. This is in line with
Andersen et al. BMC Family Practice (2019) 20:89
the findings in a previous literature review [8]. Radiolo-
gists and other specialties have raised the question of
whether GPs as generalists can carry out ultrasound ex-
aminations within all areas, and have expressed a need
for organisational restrictions [1, 26, 27]. However, pre-
vious research has shown that GPs do not necessarily
follow guidelines [28]. The GPs in our study had made
their own restrictions and selected their own curricula
of ultrasound examination based on experience. All GPs
in the present study had participated in ultrasound train-
ing, but their catalogues were determined by their indi-
vidual experiences and they did not stay within their
comfort zone. Although some of the GPs were aware of
the recommended list of scans for GPs – the DSAM
“common trunk” – none of the GPs scanned solely ac-
cording to this list. Since previous studies have shown
that some ultrasound examinations may be more diffi-
cult to learn, more time-consuming and carry a higher
risk of causing harm to patients [8], restrictions may
serve to guide the GPs in appropriate use. However, too
many restrictions may limit the development of skills
and competences.
This study describes how the lack of evidence-based
guidelines for education and use of ultrasonography by
GPs makes ultrasonography in general practice any indi-
vidual’s game. GPs are left to navigate themselves
through choosing equipment, selecting the right train-
ing, making sure to maintain skills and selecting which
examinations to perform on patients. Some of the GPs
described how ultrasonography increased the consult-
ation time and this might increase GP workload and
affect accessibility for patients. These findings may ex-
tend beyond general practice and apply to other clini-
cians and implementation of other new technologies.
Recently, an American guideline has been developed
for ultrasound training of family medicine residents [13].
This guideline is based primarily on evidence from a
hospital setting and is very comprehensive, and hence
not necessarily applicable for GPs working in primary
care. To be implemented and to avoid spectrum bias, an
evidence-based guideline for GP ultrasound examina-
tions must reflect the patient population and the work-
ing conditions in the relevant general practice. Future
research should investigate which ultrasound examina-
tions are relevant in the general practice setting and can
be performed with adequate diagnostic precision, how
ultrasound competence is reached and maintained, and
how the use of ultrasonography in general practice af-
fects patient care in the long term.
Conclusion
This study describes how GPs have found their own way
of using ultrasonography in primary care. The GPs were
highly motivated to use ultrasound and described
Page 10 of 11
increased job enthusiasm and professional satisfaction.
They selected a personal catalogue of focused ultrasound
examinations that were applicable, relevant and mean-
ingful in their daily clinical routines and had an impact
on patient care. However, they also scanned outside this
catalogue to train ultrasound competences, gain new
competences and explore possible explanations for a pa-
tient’s symptoms. When the GPs extended their usual
ultrasound catalogue, they were motivated by curiosity
and a fascination for the technology. This study may
serve to inform an implementation strategy for ultrason-
ography and other technological innovations in general
practice by offering insights into central aspects that
drive GPs’ behaviour.
Additional files
Additional file 1: DSAM common trunk. This additional file provided
the recommended list of ultrasound examinations suitable for general
practice as suggested by the Danish ultrasound society for general
practice. (PDF 455 kb)
Additional file 2: Collected background information. This additional file
describes the collected background information use in the recruitment of
participant for this study. (PDF 394 kb)
Additional file 3: Interview guide. This additional file provides the
interview guide used in the study. (PDF 555 kb)
Abbreviations
CRP: C-reactive protein; DSAM: The Danish College of General Practitioners;
ECG: Electro cardiogram; GP: General Practitioner
Acknowledgements
The authors would like to thank the participating GPs for their individual
unique contributions to this study. Furthermore, we would like to thank the
Danish Committee of Multipractice Studies in General Practice and the
Danish society for ultrasonography in general practice (DAUS) for supporting
this study.
Author contributions
CAA, ASD, JB, OG and MBJ designed the study and developed the interview
guide. CAA conducted all interviews and transcribed these. CAA supervised
by ASD conducted coding and analysis. JB, OG and MBJ reviewed and
commented on emerging themes during datanalysis. CAA and ASD drafted
the first draft manuscript. All authors contributed significantly in the revising
of the manuscript and agreed on the final version for submission to BMC.
Funding
This study is independent research funded by Center for General Practice at
Aalborg University, Denmark and the Danish Committee of Multipractice
Studies in General Practice.
Availability of data and materials
The anonymized transcriptions and analytic datasets are available stored at
Center for General practice at Aalborg University, Denmark according to
regulations by the Danish Data Protection Agency. Anonymized data are
available on request by contacting the corresponding author.
Ethics approval and consent to participate
This study was approved by the Danish Data Protection Agency (2016-41-4768)
and the Danish Committee of Multipractice Studies in General Practice
(MPU-20-2016). According to Danish law, no ethical approval was
needed for this study.
Andersen et al. BMC Family Practice (2019) 20:89 Page 11 of 11

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